Report on the epidemiological situation of onchocerciasis in Côte d’Ivoire and Guinea-Bissau five years after closure of the OCP

tJOINT ACTION FORUM Office of the Chairman JOINT ACTION FORUil,I Thirteenth session African Progamme for Onchocerciasis Control (APOC) Programme africain de lutte contre l'onchocercose JAF-FAC FORUM D'ACTION COMMUNE Bureau du Pr6sident JAF13/INF/DOC.2 ORIGINAL:FRENCH November 2007Brussels, Belgium, 4-7 December 2007 Item l7 of the Provisional Agenda REPORT ON THE EPIDEMIOLOGICAL SITUATION OF ONCHOCERCIASIS IN COTE D'IVOIRE AND GUINEA BISSAU FIVE YEARS AFTER THE CLOSURE OF TTIE OCP t World Health 0rgan ization a EPIDEMIOLOGIGAL SITUATION OF ONGHOGERGIASIS IN GOTE D'IVOIRE AND GUINEA BISSAU FIVE YEARS AFTER THE CLOSURE OF THE OCP JAF13/INF IDOC,z Page i Table of Contents I. EPIDEMIOLOGICAL SITUATION OF ONCHOCERCIASIS IN THE REPUBLIC OF COTE D'IVOIRE Recall........ General information on onchocerciasis Vector control...... Chemotherapy control Epidemiological evaluation network.. Detailed results of epidemiological evaluations General issues.... Annexes II.EPIDEMIOLOGICAL SITUATION OF ONCHOCERCIASIS IN GUINEA BISSAU General information Onchocerciasis in Guinea Bissau Onchocerciasis control Results of epidemiological evaluation Comment and recommendations Annexes I 1 I 2 J 4 4 .... 1 1 ....14 29 29 30 3l 32 -jJ JAF13/INF IDOC,2 Page 1 I EPIDEMIOLOGICAL SITUATION OF ONCHOCERCIASIS IN THE REPUBLIC OF COTE D'IVOIRE Recall General information on onchocerciasis The entire territory of Cote d'Ivoire is located in the West African onchocerciasis zone. All of its river basins are affected: the great north-south Atlantic basins of the Cavally, of the Sassandra, of the Bandama and of the Comoe, Atlantic coastal rivers (San Pedro, Niouniourou, Boubo, Go, AgnebY, M€, Bia, Tanoe, etc.), upper basins of north-south sub- tributaries of the Niger, reaches of the Black Volta, which border on Ghana and its tributaries on the right bank. From the outset, epidemiological characteristics showed gradual evolution from north to south, in line with the phasing of a guinea climate with a marked dry season and savannah landscape in the north, which turns into a sub-equatorial increasingly humid climate, coupled with vegetation that gets denser as one moves toward the south. In the northern half of the country, and in the proximity of rivers, one finds the savannah type of onchocerciasis, characterized by very high rates of blindness and eye lesions, as well as the depopulation of vast lands along water bodies; this region had some of the worst known foci: upper basins of the Sassandra, the Bandama, the Comoe and the Ivorian-Ghanaian reach of the Black Volta. In the southem half of the country, onchocerciasis gradually takes to epiderniological characteristics that indicate the forest type: serious eye lesions (blinding) were exceptional here and bordering lands remained occupied and used by inhabitants, even where infection prevalence could be as high as obtains in the savannah zone, and rural dwellers suffered frorn painful and disabling skin lesions as their compatriots of the savanna-h areas. These epidemiological differences were coupled with a differential distribution of black fly populations of the Simulium damnosum s./. complex (characterized by their identity, bio- ecology and their vector role) and Onchocerca volvulus forms. In relation to the deforestation and low rainfall in the last decades, one now observes a marked translation toward the southern part of the savannah zone, coupled with a gradual re<iuction in the size of the southern humici anti wooricd regioris (a process caiied < savannization >). At the same time, a movement was noticed from the area of distribution of the S. damnosurn, species transmitting savannah-type onchocerciasis (blinding type) toward the south, where they replace, sometimes in great numbers and for increasingly longer periods, the more stable local strains of the humid zones associated with forest-type onchocerciasis. The epidemiological consequences of this change in vector-parasite couples are not well-known. The most fearful aspect of it is, naturally, the extension of transmission of an onchocerciasis type that is potentially btinding to the humid southern part of the country, which was formerly wooded and free from this severe form of the disease. JAFl3/INF/DOC.2 Page2 It is to be noted that apart from onchocercal transmission, and due to the very high flow rates and the big rapids of lower streams of the big Atlantic rivers, these southem foci (but also sometimes foci located further north) also constitute pockets of nuisance that are very detrimental to nearby agro-industries, due simply to bites of thousands of female S. damnosum s./. from immense pre-imaginal breeding sites. Vector control Onchocerciasis vector control started in Cote d'Ivoire in the upper Bandama basin, and initially on the upper Bagoe (as well as on the Leraba and in the adjacent foci of Sikasso in Mali and the upper basins of the Black Volta and the Comoe in the then Upper Volta (now Burkina Faso) in the mid 1960s under the EDF-OCCGE campaign; this continued until 1974. These operations enabled the upper Bandama to be developed in optimal conditions of protection against river blindness. These foci were, beginning 1975, integrated into the first phase of aerial vector control operations of OCP. Since this programme, which exclusively centred its action on foci, where blinding onchocerciasis made the development of valleys impossible, operations were limited to the south by the lower Kossou lake on the Bandama, Fetekro on the Nzi and by the Serebor-r/Groumania on the middle Comoe; the river basins located in the west of that of the White Bandama were also excluded. Treatment was extended to the upper basins of the sub-tributaries of the Niger (upper Baoule, upper and tributaries) beginning 1977 under the third operational phase of OCP, which covered all the basins of tributaries of the right bank of the Niger. Entomological and epidemiological studies had shown that vectors and savannah epidemiological characteristics were found in adjacent foci (to the west and south), which are not included in the initial plans, and this put basins under the OCP Phase I at risk of contamination; an extension of operations (4ft OCP operational phase) therefore involved, beginning 1979, the basin of upper and middle Sassandra, that of the Marahoue, lower Bandama downstream of the Kossou Lake, the lower Nzi basin, around the middle and lower Comoe up to Koutoukro. This 4th phase is still called in Cote d'Ivoire "the South Extension" in relation to the regions covered by Phases I and II of OCP, known as the Original Area. Downstream, and south of this OCP area, more or less vast forest areas were never put under larviciding on a regular basis against onchocercal transmission, these were: the Cavally basin, lower basins of the Sassandra, Davo and the coastal rivers, extreme south of lower Bandama ^-l l^--,^- rr^* ^^4ll(l luwEt \-ullluE. On the basis of local entomo-epidemiological results and those in the adjacent foci (control of re-invasion risks), aerial vector control treatment of OCP was definitely intemrpted as follows (year of start-up of treatment in parenthesis): - 1989 on the basins of upper Comoe and Black Volta (1975). - 1993 on the basins of upper Bandama, upper Nzi and middle Comoe (1975). - 1994 on the upper basins of the Bagoe and Baoule and on the Upper Bandama stretch between Bou confluent and Kossou lake (1977). - 1995 on the Nzo (1979). - 1997 on the Marahoue basin (1979). JAFl3/INF IDOC.2 Page 3 - 1998 on the upper Sassandra basin, the Lobo, lower Bandama, middle and lower Nzi and middle and lower Comoe (1979). - 2001 on the middle Sassandra basin (1979). Chemotherapy control While timely DEC campaigns had been undertaken here and there in Cote d'Ivoire in the 1950s and 1960s, no national-scale chemotherapy operation was carried out prior to the introduction of ivermectin. Ivermectin (Mectizan@) was introduced into Cote d'Ivoire in 1988: Up to 1996, it was distributed by mobile teams, or passively in health centres. Beginning 1997, Community- Directed Treatment with Ivermectin (CDTI) was set up; a strategy that enables communities themselves to take charge of drug distribution through village distributors/community- directed distributors (CDDs), selected, mandated and controlled by the communities and trained in methods standardized by the national control programme. The epidemiological status of the entire country, which is the result of a combined action of vector control and ivermectin treatment, was deemed quite safe (cf. maps I and 2) to the extent that, even prior to the closure of OCP at the end of 2002,larviciding were definitely stopped everywhere in Cote d'Ivoire, without rururing the risk of recrudescence of transmission that could not be controlled by ivermectin through activities of the National Oncho control Programme OfOCP) of Cote d'Ivoire (PNLO). Consequently, no focus in Cote d'Ivoire was part of the Special Intervention Zone (SIZ), where CDTI would have been reinforced for a number of years, with external financial and technical support, with or without the continuation of vector control. Since the closure of the OCP (beginning 2003), treatment through CDTI of the entire Ivorian territory, including the southern forest area, which was never part of OCP interventions, are under the sole responsibility of the NOCP of Cote d'Ivoire. When, beginning 2005, various working groups and fora had discussions on the future of onchocerciasis control in Africa, particularly on the achievement of APOC's objectives and safeguarding of health, social and economic gains of the OCP, there were increased concerns as to the potential change in the epidemiological situation in Cote d'Ivoire. Considering the prolonged upheavals the country was going through, there were fears of disruption of control and surveillance activities and the recrudescence of onchocercal transmission. Given the initial seriousness of the disease, and the fact that several river basins extend into neighbouring countries (Sassandra into Guinea, sub+ributaries of the Niger into Mali, the Comoe-Leraba into Burkina Faso, the Black Volta into Burkina Faso and Ghana), this could be a source of re-contamination for all the cleaned-up countries of the former OCP, and could jeopardize the gains of this Programme. The conduct of intensive investigations on the current status of CDTI and parasiteientomological/epidemiological parameters was therefore decided. Recall that in Cote d'Ivoire the resistance of S. damnosum to temephos, then to other organo-phosphorous insecticides was proven for the first time, which forced the OCP to develop a double policy on selecting chemicals and on insecticide operational rotation, which proved very efficacious. JAFI3iINF/DOC.2 Page 4 Epidemiological evaluation network Cote d'Ivoire has an intricate network of standardized epidemiological surveillance, which was put in place by the OCP in more than 340 hyper-endemic villages. The network covers all the river basins in the country along the major rivers and tributaries. The network was regularly monitored until early 2000s (averagely nearly 6 visits per village) and complemented with selective evaluations. Since 2000-2002, and the evaluations preceding the closure of OCP, only two epidemiological surveys took place in some basins in 2005 (19 villages) and 2006 (9 villages) under unspecified standardization conditions, that do not allow results to be validated with certainty; results will, therefore, be referred to with all reserve. Only one of the villages surveyed in 2005 and another of those surveyed in2O06 were visited in 2007. Only 4 of the villages visited in 2005 were previously seen in conformity with the standards (1993-1995-1996 and 2001): 5 of the villages suweyed in 2005 (only for prevalence) had been surveyed in a standard manner in 1997 (a) and 200 I ( 1 ). The survey of June - July 2007, carried out with a rigorous methodology, had to do with 38 villages, which were well distributed for sampling the various foci. Only one of them was visited for the first time, while the others were visited on the average 5.5 times from the beginning of treatment. Only 10 of these 38 villages had already been visitedin2000-2002, and trnfortunately, they are mainly in two basins (Sassandra: 6, Comoe: 3, Nzi: l). The others were seen in 1992 (3), 1993 (3), 1994 (1), 1995 (2), 1996 (2), 1997 (10), 1998 (3) and 1999 (2). The outcomes of the epidemiological evaluations conducted in June - July 2007 are summed up in tables I and 2. In the following analyses, the epidemiological situation is expressed but in terms of standardized or corrected microfilarial prevalence (PVL in %) and in community microfilarial loads (CMFL in numbers of mf/skin snip). The results reveal that 28 villages out of 38 (77.8 %o) have a microfilarial prevalence below the acceptable threshold of 5 %o, wrth 1 6 of them having a zero prevalence (42,1 %);32 out of 38 (88,9 %o) have CMFLs below the acceptable threshold of 0.5 mf/s.s., 17 (44,7 %o) have a CMFL that is nil, and 11 others CMFLs that are only positives to the second decimal point (< 0,1 mf/s.s.). Apart from the 38 villages mentioned above, it came out that six others were evaluated by the NOCP team of Cote d'Ivoire in August 2007 on Upper Comoe around the Bouna reserve, apparently to allevtate concerns of the inhabitants, who were complaining of biting nuisonce caused by S. damnosum s.1.. Supposing that the coruesponding surveys had respected the same normalization rules as those of July - August, what remains to be proven - results of these villages - do not affect preceding observations concerning the 38 others. Detailed results of epidemiological evaluations Unper basins of sub-tributaries of the rieht bank of River Niser These rivers mn generally from south to north, are close to their sorrces and feed the Dion, major tributary of the Niger in Guinea (Gbanhala, Kouroukele), either the Baoule and the JAFl3/INF IDOC.2 Page 5 Bagoe (which, together, form the Bani) major tributary of the Niger in Mali (Baoule, Degou, Mahanbadiani-Kankelaba, B agoe and Niangboue) Ln2007, infection is nil on Upper Bagoe (Kebeko and Gbando), where it became "tolerable" from 1 991-93; it is insignificant (PVL 0.4 yo, CMFL 0.01 at Beniasso) on upper Kanlelaba, which underwent massive re-invasion further downstream in Mali. There is no data on the other basins of this region for 2007. In 2000-2002, transmission could not be detected on upper Bagoe (Guinguerini and Kassiolo), the Degou (Missamahana) and the Baoule (Salonkourani and Tiemba). Though below the tolerable threshold, it was detectable at Missasso (PVL 4.2 o , CMFL 0.17) on the Bagoe and, especially on the Gbanhala (upper Sankarani, PVL 6 %, CMFL 0.6, at Gbanhala, values that are just above acceptable thresholds) and a degree less on its tributary of the Kouroukele (PYL2.2Yo,CMFL 0.13 at Farala). Results of 2007 are therefore excellent, especially with respect to non-isolated upper basins of the downstream, where treatment eluded the Ivorian authorities. Sassandra basin Upper Sassandra. This means all the large perennial and undulating water courses taking their source frorn Guinea, and whose confluences are close to each other: the Bagbe, into which empties the Boa, which is, itself, fed by the Sien and the Tiemba forming thus the Sassandra. In 2007, the Boa was sampled near its point of entry into Cote d'lvoire (Lamouedougolr, PVL 0.7 yo, CMFL 0.05, instead of 3.0 % and 0.08 respectively in 2000) and near its confluent with the Bagbe (Mamorobougou, PVL and CMFL, which;hate been nil and below acceptable thresholds since 1993). At Vialadougou, PVL of 6.90/o and CMFL of 0.41 indicate a situation that could be described as being at the limit of acceptability, and maybe slightly deteriorated, compared to that of 2000 (PVL 3.4o/o and CMFL 0.12). Figure I In 2000-2002, the situation was excellent, with no infections on the Sien (Massabouedougou and Doumba) and upstream of the Boa (Vakavadougou), as well as on the Bagbe: no infection at Touresso II, PVL 0.5 % and zero CMFL atNgorondougou. Giventhe configuration of this focus, which had the worst clinical situation in the 1970s in the region, particularly around Vialadougou, these results are very satisfactory. They show that the situation is under control in a sustainable manner, even in border areas in a complex focus. Vialadougou is the epicentre of the focus, in the midst of action of four foci that are extensive black fly producers, and the population here has gone through a lot of hazards since the end of the 1970s: settlements were reduced prior to this period, then came deforestation, inflow of work hands during development work, sugarcane plantations, then came the decline of the latter and so on and so forth. Middle Sassandra- Sassandra River, downstream of the Bagbe-Boa confluent, including tlre Bafing, which actually is the upper Sassandra, up to the former southern limit of the ex-OCP, set at the Semien ftry, then the Buyo Lake. JAF13/INF/DOC.2 Page 6 In 2007, between the confluents of the Bagbe and the Bafing, the situation changes from the absence of infection in the south at Soribadougou, where PVL and CMFL were 8.5 Yo and, 0.28 respectively in 2000) with infection situations that are well below acceptable thresholds at Webasso (PVL 1.2%; CMFL 0.00 in 2007, as against 0.7Yo and 0.02 in 2000) and at Sorotana (PVL of 2.8Yo, CMFL of 0.02% in2007, as compared to the PVL of 2.2 yo, CMFL of 0.08 in1997,andPVL of l.lo/o,CMFLof 0.01 in2000).Figure2 Once again, this is a situation that is apparently stable or an improved one, which is also very satisfactory, given the difficulties encountered to bring transmission under control during the OCP period (intemrption of larviciding only in 2001) The Bafing basin, which was not visited in2007, had been cleaned up right from 2000-2001: PVL and CMFL are nil atZotzousso II and Guiane (on a tributary). Downstream of the confluent of the Bafing, the only village visited in 2000 and 2007 (Piebly- Dioulabougou, near the southern boundary of Phase IV of OCP, shows some improvement: PVL dropping from 8.8 to l.5o/o and CMFL from 0.55 to 0.05 mf/snip. Other points nearer to the Bafing confluent showed in2000-2001 results that were lower than the tolerable thresholds (Kohola: PVL 0.9 oh, C}l.ffL 0.02; Adjame (PVL 2.3yo, CMFL 0.03) or slightly above the thresholds (Lotou, PYL 6.3%, CMFL 0.14; Krakro, PVL 6.4yo, CMFL 0.33). As obtained on the previous reach, the epidemiological situation appears very satisfactory, considering the size and history of this focus. Nzo. At Petit Yapleu, the only survey point in 2000 on the Nzo, main tributary of the Sassandra, the situation appeared rather unsatisfactory, close to meso-endemicity (PVL 21.3, CMFL 0.52) and especially stable since 1995 at the least. With the reserves already put forth concerning the 2005 surveys, prevalence results for that year at Akakro III on the Lobo (6.6%), at Djane Kouakoukro on upper Gore, tributary of the Lobo (3.2%o) and on the Sassandra at Koperagui, in the south of Soubre, in the area, not included in the OCP area (24.5o/o, compared to 62.70/o during the standardized survey of 1996). One site seems to have posed a problem that is Mafia, on the Lame, tributary of upper Lobo. In tQOO o-.{ 1AA1 D\-If L^.^ \1,^?4 1l n anA AQ 1ol -a^^^^+:-,^1., ^-l rrl\rDT ..,^-^ o aA ^-) . n.t\LrL t)r) attv LvvLr l yL rlvlv w\,i\, /u.z aiiu io.z.ro igsPcutivEiJ iili.u Livl.i-L were 6.0+ anc j.vu respectively. The 2005 survey might still have indicated a prevalence of 15.30% with no indication on the CMFL. Bandama basin Upper Bandama basin This reach is between the source of the river and the end of Lake Kossou, including the tributaries: the Badenou, Solomougou and the Bou. JAFl3/TNF IDOC.2 PageT The survey of 2007 had to do with: o the upstream of upper Bandama: Tawanra-Djero and Fodiolokaha: infection is nil, and the situation has been normalized since 1989; o the reach between the confluent of the Bou and the Kossou lake: similarly, at Guesso- Bondosso, infection is nil, and the situation normalized since 1999; figure 3 o middle Bou (Bissidougou) and lower Bou near its confluent (Dikodougou): infection rates have been nil 1993. Surveys from 2000-2002 centred on: o upstream of upper Bandama and its tributary, the Badenou: infection here is nil (Badenou I and II, the Nawolavogo, the Daoudadjanvogo) or very low (Fodonkaha, PVL 1.0%, CMFL 0.05) and the Longo (PVL 0.2oh, CMFL 0.00) ; o the Bandama downstream of the confluent of the Bou: infection is nil at Badala- Odienne; o the Solomougou: infection is nil at Bapolkaha, Golokaha and Tripoungo (since 1989 in the latter case); . upstream of Bou (Tiolokaha, PVL 3.4, CMFL 0.03, acceptable values) and downstrearn Qrlagoungokaha, PVL 7.1, CMFL 0.40, sub-normal values). These results are spectacular for whoever knew the historic focus of upper Bandama in the 1960s, when population pressrue and the lack of land forced the Senoufo populations on the right bank to risk their sight on the banks of the river, whereas on the right bank, which was sparsely populated by Tagwana populations, long ago decimated by Samory, onchocerciasis kept away a deserted 20-km width of land. Though villages surveyed on the Bou in 2007 xe different from those visited in 2000-2002, it is possible to envision improvement in the epidemiological situation on this river. Lower Bandama 2007: No infection at Sawa (on the Taabo dam?). Further downstream at Awaoti (as Aouti in the entomological evaluation) PVL is 9.5oh and CMFL 0.28: this situation appears to be stable since 1997 (PVL 8.3, CMFL 0.30), the year these parameters dropped drastically (PVL 52.4 CMFL 5.41 5 years earlier). Figure 4. These sites, located between the Kossou dam and the Nzi-Bandama confluent are in an intermediate area (V Baoule) south of which transmission, hitherto forest-type mainly through savannah vectors, has taken over. In ?OO! nn fhe qqme r"canh s!!flrc,q cenfrerl nn Ghnohnhn /P\/T 'l ? 6 qnd CIVIFI 0 4?\ and theLll LwwL) vll ltlw Jglllv rvsvlr, Jsr vvJu vv^ro^vg vri vvvbvv u:u iii_- Sahoua Camp (PVL 4.9; CMFL 0.13), at Dupuy-Yao, at the Nzi-Bandama confluent. Prevalence was 8.5 and CMFL, 0.37. (NB: 2005 survey, with reserve of what the results were used for, indicated 12.3% for PVL in the same site). Though slightly behind the results of the upstream basin, these results show very marked improvement in the epidemiological situation in the region, where great vector densities harze the potential to maintain infection rates, even if epidemiological characteristics indicate the forest type, and where populations have undergone considerable changes (economy of plantations replacing forest exploitation, deforestation, urbanization, big worksite s, establishment of agro-industries, etc.). JAF13/INF/DOC.2 Page 8 Marahoue basin Though Marahoue @ed Bandama) is actually a tributary of the Bandama (White Bandama), the importance of its basin warrants separate treatment from the Bandama. This basin is entirely in area IV of the former OCP and in the savannah Oncho area. Upper Marahoue basin: Marahoue, Yarani and Bere, and their tributaries upstream of the Bere confluent. Upstream rn 2007, (Farandougou) infection has been nil since 1997; further downstream (Soulemanekaha at the confluent of the Yarani), residual prevalence (2.9 %) and CMFL (0.12 mf) are low. In 2001, infection was nil on lower Yarani (Djenigbe) Lower Marahoue. Reach between the confluent of the Bere and the confluent of the Bandama. In 2007 at Vrehenfla (downstream of the Bere confluent), infection is nil, and the situation has been deemed acceptable since 1994. At Danangoro (downstream of the reach, downstream at the confluent with the Bandama), PVL is 0.5%o and CMFL 0.02 s.s. It must recalled that the survey of 2006 showed no infection upstream of upper Marahoue (Campement Marahoue), on the Marahoue just upstream (Gondje) and just downstream of the confluent with the Yarani (Niangoro), as well as on lower Yarani upstream of this confluent (Feed-Lot). On the Marahoue, just upstream, the village of Bada Ghanasso showed a PVL of 2.7Yo and a CMFL of 0.12, and further downstream, another (Dantogo) was close to the tolerable threshold (PVL 5.6yo, CMFL of 0.14). In 2000-2001, just downstream of the confluent of the Bere, infections were nil (Tyefla and Klazra) or very low (PVL 1.1, CMFL 0.04 at Kavaka) The Marahoue basin, which is an important focus, by its size and gravity in relation to its hydrography and oreography, seems correctly cleaned up on the whole. The Nzi basin Just like the Marahoue, the Nzi, main tributary of the right bank of the Bandama, constitutes a vast savannah Oncho basin, which needs to be given specific attention. Upper Nzi basin Reach between the source of the Nzi and the southern boundary of Phase I of OCP, near Fetekro. In2007, upstream of the Nzi at Kolonkaha, PVL is 1.5% and CMFL is 0.04, which are low, comparedtocrudedataof 0.0%and0.00s.sof2001,0.8%and0.02s.sof 1998, and0.6Yo and 0.01 s.s of 1995. At Gboli-Canefour downstream of this reach, the same parameters indicate L5Yo and 0.03 s.s and have appeared to be stable since 1997. JAFl3/INF IDOC.2 Page 9 In 2000-2002, on the most upper part of the basin, there was no infection (Lamekaha III, Niaretenkaha, Koulokaha) or it was low ( PVL 1.7 yo, CMFL 0.03 at Yedandiakaha, PVL 0.5yo, CMFL 0.03 at Guiendana, PVL 0.8yo, CMFL 0.01 at Korodjala), except Kobadara, where PVL reached 9.2% for a CMFL of 0.23. On the middle part of this reach, Sende- Sokoura showed no infection, while Loho and Solokatra showed PVL of 3.2 and l.4Yo and CMFLs of 0.19 and 0.04 s.s respectively. Further downstream, three villages exceeded the tolerable PVL slightly: Kokola (7.5 %), Nambayeredougou (6.3%) and Namilohokaha (7.7 %), while CMFLs (0.45, 0.20 and 0.16 s.s respectively) remained below the tolerable threshold. Basin of middle and lowerNzi ln 2007, upstream of the reach, infection is nil at Fetekro, where it was within acceptable standards in 1994, figure 5, downstream of the reach. Upstream of the confluent of the Kan, the situation is acceptable at Koukoukro (PVL 2.3yo, CMFL 0.07), whereas downstream of the confluent on the lower reach at Laourebo, PVL slightly exceeds the tolerable threshold (6.2% whereas the CMFL remains acceptable (0.29 s.s). Laourebo shows, in relation to 1997, the first year of dropping of parameters below acceptable thresholds (PVL 3.7yo, CMFL 0.07) a recrudescence trend (PVL x 1.7, CMFL x 4.1) the significance of which must be assessed: Figure 6.Data of Lomo-Nord downstream of the Kan, is however very satisfactory: PVL 1.0 and CMFL 0.03. In 2000-2002, surveys upstream of this reach, on both sides of the confluent of the Mbe, revealed a PVL of 4.5Yo, CMFL of 0.06 s.s at Languira, and a PVL of 1.8% and a CMFL of 0.01 at Goli-Nzikro. Downstream of the Nzi in the area of confluence with the Kan, the situation was satisfactory at Dida-Nglossou (PVL 0.gyo, CMFL 0.04), by far less at Yobouebo II (PVL 11.8, CMFL 0.33) and at Feteassou (PVL 13.5, CMFL 0.43). The situation was satisfactory on the Kan: PVL 2:1, CMFL 0.04 at Asser6kro. ;" . .." t' Despite some shady areas orithe'middle course and the tail end, the situation of the Nzi basin is proof of satisfactory and apparently prolonged control of transmission. Black Volta basin The Black Volta is a natural border between Ghana and Cote d'Ivoire and runs over about fifty kilometres in the extreme northern part of the country. Besides this reach of the river, the basin includes some of its right bank tributaries, which wholly flow into Cote d'lvoire or join the river in Burkina Faso (Kamba, Poueme) or into Ghana (Kohodio). ln 2007, Pieye on the river shows a prevalence of 4.7o/o and a CMFL of 0.1 s.s; these parameters dropped below acceptable thresholds in 1993 (PVL and CMFL were then l.60/o and 0.08 respectively). At Kamala on the Kohodio tributary infection is nil, since the two surveillance parameters also became normal in 1993. In 2002-2003, the situation prevalence was merely acceptable at Vonkoro-Mali on the river (PVL 6.4%, but CMFL was 0.02). It was very good on two tributaries that end up in Burkina Faso, i.e. the Kanba (PVL 1.7, CMFL 0.04 a Nakele) and the Poueme (PVL 0.7yo, CMFL 0.02 at Lagbo) JAF13/INF/DOC.2 Page l0 The Comoe basin Upper Comoe basin Upper reach of the river on its Ivorian course up to about Ganse, including the long reach of east Leraba, then from the Leraba, and then from the Comoe itself (from upstream toward downstream, these three rivers take their source from Burkina Faso) which is on the border with Burkina Faso. It is a Guinean savannah Oncho savannah-type included in the ex-Phase I ofOCP. In 2007 , surveys were conducted on Ganse, which is downstream of this reach (PVL 1.2 yo, CMFL 0.00), a cleaned-up site since 1993, with PVLs and CMFLs which were then nil, as in 1997) and Toumbo-Yaga (no infection) on the Kongo, left-bank tributary where PVL and CMFL rn2002 were 0.6Yo and 0.02 respectively. In 2002, at Daoudadjanvogo, the epidemiological situation was good (PVL l.8oA, CMFL 0.07); at Kafolo further upstream, it was sub-normal (PVL 4.9 yo, CMFL 0.13). on the Iringou at Trypano, the situation was satisfactory: PVL 1.6 yo, CMFL 0.02. Results of August 2007 might have indicated relative increase in prevalence (8.7%) at Kafolo and Bawe on the tributary called Bave (PVL 8.0% as compared to 0 in 1997), whereas CMFLs remain low: 0.19 at Kafolo and 0.06 at Bawe (as against 0.0 in 1,997).In the other four villages surveyed on the tributaries CMFLs are nil in all places and PVLs are nil (Toro Kinkene on the Kinkene, Nassian on the Kolonkoko, Kongolo) or very low (0.6% at Toro Lewara on the Kinkene), with these values apparently being stables since 1997. Middle Comoe basin Reach running from Ganse to the confluents of Diore and Bayakokore approximately. It spans Phases I and IV of OCP. Here, Oncho is of the savannah type, and no village of this reach was surveyed in2007. In 2000-2002, results were satisfactory on the Comoe at Amaradougou (PVL l.4yo, CMFL 0.04, at Awahikro (PVL l.7yo, CMFL 0.03) and at Gbagba-Sirakoro (PVL 0.7yo, CMFL 0.01), as well as on the Diore (Aferi PVL I .2yo, CI\IFL 0.01). Lower Comoe Reach between the Diore confluent and the mouth of the Comoe. It is found in area IV of OCP, except for the completely terminal course, which was outside the OCP area, and whose treatment was only through CDTI under the NOCP. Onchocerciasis was gradually becoming the forest type per its epidemiological characteristics, which was well characterized from the Betie latitude. Transmission conditions here now seem to be changing fast, in favour of an increase or even dominance of transmission by savannah populations of the S. damnosum complex that are becoming perennial, to the detriment of forest vector populations, which were almost exclusively present some decades earlier. In2007, the situation is satisfactory at Assemanou, figure 7 (PVL 1.5 yo, CMFL 0.01); it deteriorates gradually towards the south: it is sub-normal at Ahininkro,(Pvl 5.9%o, CMFL 0.17; with the non-validated survey of 2005 indicating zero PVLs and CMFLs in this JAF13/INF IDOC,2 Page I I village) ; it is unacceptable at Blekoum, figure 8 (PVL l8.3Yo, CMFL 0.52) and at Abradinou (PYL 183%, CMFL 0.96), with the two parameters being stable in the two villages since 1995 @lekoum, PVL 20.2yo, CMFL 0.48; Abradinou, PYL24.0, CMFL 0'80). Results from 2000-2002 obtained on the same reach in villages different from those surveyed in2007 were reminiscent of those for this year: upstream, Flamebo (PVL and CMFL are nil), NGatta-Kouadiokro (PVL 6.80 , CMFL 0.44), NGuessan-Konankro (PVL 3.8o , CMFL 0.ll), Kokonou (PVL 2.2yo, CMFL 0.04), fruther upstream SCAF (PVL 3.2o , CMFL 0.06), Campement Barnab6 (PVL 13 o , CMFL 0.18), Abradine II (PVL 0.5oA, CMFL 0.02). In the extreme south, at Awowonkro, figure 9 (PVL 32.9yo, CMFL 1.69) and Monekoi (PVL 39.3oh, CMFL 2.72), the situation is even less satisfactory, and values of the two parameters seem to have increased since 2002 (Awowonkro PYL 195%, CMFL 0.74; Monekoi PVL 18.8, CMFL 1.03), the year in which a drastic drop was recorded, in relation to figures of 1997 (Awowonkro PYL 64.1%, CMFL 7.82; Monekoi PVL 76.6yo, CMFL 17.62). Similar results (Alosso, PVL 18.3%, CMFL 0.58; Nianda, PVL l2.0oA, CMFL 0.41), or worst ones, were recorded at the beginning of the 2000s in other sites at the extreme southern part of the reach, with PVL and CMFL values that question the achievement of CDTI in some villages: for instance, Koutoukro I (PVL 64.2yo, CMFL 10.06 in 2002,72.8oA,8.57 in 1997) and Koutoukro II (PVL 54.lyo, CMFL 5.25 in2002,71.3oh,11'08 in 1997). General observations The first observation is about the overall quality of results as revealed by the June-July 2007 survey, since except the rare cases reported about each basin, the epidemiological situation established from values recorded for standardized prevalence rates and CMFLs seem to be compatible in almost all the sampled focj with selected tolerable tluesholds, which allow for avoiding clinical risks and the recrudescence of transmission. These results are reassuring per se, with respect to the current human infection situation. It is always not easy making comparisons with previous data: multiple surveys of the period preceding the closure of OCP were centred on villages without antecedents in OCP archives; several of them were not re-visited later on, because no reliable surveys were conducted between 2002 and2007, and hardly more than a quarter of the villages surveyed in 2007 were surveyed at the beginning ofthe 2000s. In this connection, it would be useful to try and retrieve fro the NOCP of Cote d'Ivoire crude data of epidemiological surveys carried out in 2005 and 2006 by national teams alone, in order to validate, to the extent feasible, their results. It is, however, possible to affrrm that since the closure of the OCP, in all the river basins, and on almost all the reaches, results were generally maintained at the same level, or even improved, compared to the endemicity rates recordedin 1997 and upon closure of the OCP. When evaluations were repeated at convenient time intervals, the corresponding curves practically always show a sudden drop of the two parameters for 1997, whatever the basins and the subsequent line of the curves. Without excluding other possible factors, this blanket concomitance cannot for the time being, be attributed but to the generalised establishment of JAFl3/INF/DOC.2 Page 12 CDTI in 1997. It would, thus, underscore, if need be, the greatest effrcacy of CDTI, as compared to the other modes of distribution of ivermectin. While these results are reassuring, they constitute a surprise package, when one considers the overall CDTI data of Cote d'Ivoire available in Ouagadougou, which reveal, since the onset (1997) considerable lapses in the number of eligible villages, geographic and therapeutic coverage rates, years of treatment... The review of table 3 shows that 1997 was a year of very partial start-up of CDTI. The objective of villages and populations to be treated remained stable from 1998 to 2001, which seems to indicate that there was no prospection of new eligible communities in the areas under treatment, as obtained in areas outside these... which would have been justified, taking into consideration the increase between 1998 and 2005 in eligible community figures (+ I2.5%) and populations (+ 41.7%). Census methods are not known and this data relative to figures are to be considered with caution. It appears, in any case, that geographic coverage rates still remained below the acceptable threshold of 100% and therapeutic coverage only went beyond the acceptable threshold of 65Yo in 1998 and 1999, but with geographic coverage rates as incomplete as the number of eligible villages was underestimated. No CDTI data for 2003,2004 and 2006 is available in Ouagadougou. It is certain that the events that unsettled Cote d'Ivoire since 2000 disrupted the implementation of CDTI in this country, and more generally all activities of the NOCP. One could, however, observe that the first coup d'6tat happened only at the end of 2000, and that CDTI at the time was already weak. The situation worsenedin2002, with the partition of the country, then with the relocation of the NOCP from Bouake to Abidjan, and the loss of its survey equipment, vehicles, ivermectin stock and archives. No activity could be undertaken from September 2002 to December 2004, which explains the lack of CDTI data and results of epidemiological survey during the said period. The fact that there was no base data on epidemiological surveys of 2005 and 2006, and the lack of CDTI data in 2006 is more enigmatic, even if persistent tension in the country certainly impeded the conduct of activities. Since the unreported treatment seems to be the only assumption that could explain the large disparity between a very satisfactory epidemiological situation and a CDTI that has apparently been full of lapses since its inception, it is important to go to the source on the ground (health districts and community-directed distributors) for data and information that is as accurate as possible on the history and local realities of CDTI. The surv-ey-, which, of course is cumbersome, would be aimed to clarify the linli befween CDTI coverage quality and impact on the intensity of infection, particularly when the NOCP is not able to play its role of facilitator, coordinator and evaluator; this is useful information for several countries affected by conflict, apart from the specific case of Cote d'Ivoire. The survey will also help to ensure that, with a return to normalcy which is so yearned for, the CDTI set-up is fully operational in districts and communities, that it is in a position to safeguard the overall good quality of gains, or even improve results locally, when the latter need to be scaled up to the good quality level of the entire country. Plans must be made to ensure that this survey identifu local needs for rehabilitating CDTI, improve CDD coverage, training of the latter, resumption of awareness-raising actions and maintenance of incentives, etc.. JAF13/INF IDOC.2 Page 13 In terms of focus by focus epidemiological surveillance, the following recommendations could be made for future surveys: On sub-tributaries of the sht bank of River Niser . Despite the good results, the next epidemiological evaluations could include Upper Bagoe (Missasso) and some tributaries of the Guinea basins. On Upper Sassandra basin: Though the epidemiological evaluation results of Vialadougou are not alarming, they must be reviewed, with respect to individuals examined during the last evaluations, and the PVL and CMFL trends of 2000 to 2007 must, to the extent feasible, be analyzed. On the Middle Sassandra: Further surveys may ascertain if the clear trend in improvement recorded at Piebly-Dioulabougou was also evident from 2000 to 2007 in the other villages of the Sassandra valley nearer to the confluent of the Bafing-Sassandra Lotou, Krakro). The Bafing will also need to be evaluated in 2008. On the Nzo: The epidemiological situation will need to be evaluated soon (at least at Petit Yapleu), given the poor results of 2000 on the reach, which was formerly included in the OCP area, as well as the situation of the basin spanning the OCP area IV and the "forest" extension area of CDTI not included in OCP. Lower Sassandra: This forest extension area. downstream of the Buyo dam, should also be evaluated at the next epidemiological evaluation round, despite the dearth of reference data. The same goes for the Davo. On Upper Lobo: Considering the geographical situation of Mafia, close to the parallel basins of the Yarani and the Marahoud, a complete standard evaluation in 2008 is necessary in this village, coupled with a survey on the previous and present distribution of ivermectin. On the basin ofuooer Bandama: The next annual round of epidemiological surveys should include a village on the Bou, which was surveyed in 2000-2002 to ascertain trends on this main tributary of upper Bandama. On lower Bandama, (between Lake Taabo and the confluent of the Nzi); the villages surveyed in the f,rrst years of the century, will have to be re-visited during the next evaluations; the survey could be extended downstream up to the last great rapids. The Marahoue basin: This does not require any speciai controi, but the river and its main tributaries, particularly those upstream, are included in the resumption of a periodic surveillance network. On the middle-upper Nzi and especially lower Nzi: (area of the confluence with the Kan); it will be necessary to ascertain the epidemiological trends in comparison with the data of the early 2000s. Black Volta and its tributaries: Where the situation remains good, despite the apparent upward trend in prevalence on the river; the same surveillance policy, recommended for tlee Marahoue, certainly need to be applied here. JAFI3iINF/DOC.2 Page 14 On upper Comoe, the slight apparent upward trend of prevalence will justiff a standardized evaluation in 2008 in the other villages of the Kafolo area. Lower Comoe, which forms the lower part of this reach, is finally the only focus which needs to be taken care of again on a large scale, both in the southern part of the former phase IV of OCP and on the terminal reach, which is not included in the OCP area. In the course of the 2008 epidemiological evaluation round, a selection of villages will have to be done, by marking out the focus, beginning from the approximate latitude of Assemanou in the north, up to the last large breeding sites downstream, and preferably by retrieving villages that were previously already examined, in order to arrive at trends with a view to demarcating the focus/foci with too high persistent transmission, and specifying levels of infection. Of course, one needs to particularly pay attention to past and present CDTI implementation conditions in these foci, where enhanced entomological evaluation will be most welcome. Overall, it is necessary to re-establish a basic evaluation network in which all villages are visited over three years, with each annual survey centring on about a third of the total, but ensuring coverage of the main basins (what nearly forty annual visits could allow for). There is need to resume, as a matter of priority in 2008-2009, the villages surveyed in 2000- 2002, while putting emphasis particularly on those which had at the time, residual transmission exceeding more or less tolerable thresholds. Effort must be made in the forest zone, which was never integrated into the OCP area, and which seems to suffer both from poor quality results and dearth of epidemiological evaluation. Epidemiological surveys must be coupled with local CDTI evaluation, collection of clinical (listing of eye and skin symptoms), sociological and demographic data. This was the case dwing the 2007 survey. Antecedents of positive cases, in terms of infection, clinical manifestations, exposure to transmission (occupations, living in endemic areas, relocation of residence) followed by treatment with ivermectin, etc. will have to be systematically re-visited. The entomological evaluation network (pool-screening) must be reactivated and readjusted in conformity with the epidemiological situation of the day. In the southemmost regions, the most humid and hithertc occupied by the dense forest, it would be appropriate to evaluate in the various foci (lower Comoe, lower Bandama and lower Sassandra) that have clinical reference data, changes in the clinical situation and modes of transmission, due to the reversal of situation observed in vector populations and the indices of increase in ocular onchocerciasis. Annexes Table 1: Prevalence rates and CMFL of villages in Cote d'Ivoire evaluated in June - July2007. Table 2: Results of epidemiological evaluations of 1997 - 2007 in C6te d'Ivoire Table 3: Overview of CDTI in Cote d'Ivoire. Map 1: Prevalence of Mf in C6te d'Ivoire. Status of pre-treatment. JAF13/INF /DOC.2 Page 15 Map2 Prevalence of Mf in C6te d'Ivoire. Epidemiological evaluations from 2000-2002. Map 3: Prevalence of Mf in Cote d'Ivoire. Epidemiological evaluations of July 2007. Fig. 1: Curves of PVL and CMFL trends at Vialadougou (upper basin of the Sassandra). Fig. 2: Curves of PVL and CMFL trends at Sorotana (middle Sassandra). Fig. 3: Curves of PVL and CMFL trends at Guesso-Bondosso (upper Bandama). Fig. 4: Curves of PVL and CMFL trends at Aouati (lower Bandama). Fig. 5: Curves of PVL and CMFL trends at Fetekro (upper-middle Nzi). Fig. 6: Curves of PVL and CMFL trends at Laourebo (lower Nzi). Fig. 7: Curves of PVL and CMFL trends at Assemanou (upstream of lower Comoe, extension South area). Fig. 8: Curves of PVL and CMFL trends at Blekoum (lower middle Comoe, South extension area). Fig. 9: Curves of PVL and CMFL trends at Awonwonkro (lower Comoe, lower part, outside the south extension area). 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C\tod N(o @ @(o(o(oq @ ooo@Noo rod I ooo roq lr, I ooo tc,q lJ) t oooN @(o(o @d I ooo F-(o(o(o @d I ooo F-(o(o(o\ ro t oooF-(o(o(o\|.r, t ooo@No o,q lo I ooo@ c\to o)q ro I ooooooo ro rri I ooot-@(o @lod I (o(o @d I oooooolo\ l() I oooooolot- ri I ooo Fr(o(o(0 o, +I oool'*(o(o(o o? t I ooo o)(r) t-o d I ooooooo oq s ooooooo@ + I ooo(t,(f) @ l()N ri I oooF-(o(o(o to ooot* @(o(oq(o I ooor-(o(o(oq(o I oooooooq o ooot-(o(o c! @ ooo F-(o(o(oq(o ooot* @(o(oq(o I ooo(o o c/) @ a @ ooo(o o(r) @ a(o ooo(oo c/) @o F- I ooo @o(r) @q F*I oo F-(o @ o, c.)(o I e @o F- I o EoE L o @ o E oro E(! o o E oEc o(I) f o(n J od] l odl f o(D a od] =oc0 f odI f oof o E o o U) f o o) :, o E oEa o o)f o EoE U) f oof o E o o U) o E(I,Ec o co (5 E ooCo(n o E o!c o d) o E o!E(U d) o E G!c o tn o E(I,p c o d) (I, E oEc$dt .o =oE(E G = .q) =o oL o .o) f oc Eo = {) o -c(E o = .o) f oEo (5 = .o) f o .cg o .o) :,o -co (E = .o f o -coLo .o =oE o (E = o3o .Cg (o .o) l o -co o "() , oE o o = c alt oo o o- o.l a =oz (D c ,6 o -o o o- o- :) oz dl .coo -o Lo o. o.l =oz d) c o(s -o L o) o-o) =oz o c oo -o Lo o- o-f, a =oz (D c '6 o -o o) o- o- :) oz d] c o(g -o o o- o-f a =oz dI c t, oo o o- o.f, a =oz d] c '6 o -o Lo o- o- :) a oz d] .co o -o Lo o_ o-f =oz d) c ll, o -o q) o- o.f oz m c '6 oo Lq) o- o-l =o z d] tr 'd o -o Lo o_ o-l a =oz co c o o -o o o- o.f a oz (D =oz d] o =oJ =oz c0 o =oJ =oz (D o d] oz co q) =oJ =oz d] o =oJ =oz d] o =oJ =oz dl L o) =oJ c '6 o -o Lo o. ctf I,IJf, o - d = c oo -o L o CL CL f uJl oI t = L '6 (E .cI Lo o. o-l uJ :) oI t = c o oIt o o. 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() o m =f, oF o I oo =l oF f oof,oo G. otrY I = otY I E ovoV d -a&ao ao lo (f)(t) to (o N(f) t-@N t4, roF(f) ro F-(9 o) o,Nto st-(?) st*(o s F-(f) o) @(o F-@ Nro o)lo t- o,Nlo (o @ oo)C!lo (oloort o)@ O)@ F o) @ F-o@lo tro@lo Nf.- o, ro $lo$ ro slr)$ ro N @lo N @|r) o)o@ ro o,o@l() ro @ ro @ O)roos @ @ @ @ F JAFI3/INF/DOC.2 Page20 o o o lr) o) IrooN lr,oN (t) c\t(\t ooo F-(0(o oq F* ooo(oo(f) @q s I Nz L o 3oJ od o Ep otY tuF tu LL Nt-N xz JAFI3/INF/DOC.2 Page2l q o No ci (o o? o (r)q o @q o N c! t- s\o O)q F..q @ (oo o @q F roq lr) Nq t- (f)q N\N l() a? 1o oo o t- o so ci o ci Nlr) ci @ ci oo ci sq o o (oq o o,{ r() o \@ qo qro c? q c?6 q(o qo c!N F<"iN oq(a c!(f, c?N (f) ct s(o q o) o) oi(f) @ 6i F.- c! $@ a? t- +ro q(o N @d c?O)(f) \o(r) q N F lo (f) F.-$ lf, @$ @ @oN o, o) o, (oN rolo lr,O) cf)(fJo o (Y) CO CO(o ro o rf) l.r)N e{ (f, @ ol.c) t-N N t.- NoN t* @ O) o) f.-ro NO)N $NN (o @ lr)(o (o o)c)N @o (r) t o)@ (f)t-(r) rO\t $ roN 6(o o(o s(o N No N @ (o (f, @ sro rt (o $o,N Nt-N @ @ N (f) 1() N v\r N o rr)(o N cr) c., cf) @ F.-o(o (f)(o N o N \r N f.-(o (f)lr)N (os (o (o$ ot-$ O)(o N NN oN (r)sN (o NN (f,(o (f) O)(O N @ ro (O(O lr)$ co @ N (o @ c{ o,o(v) N(f) (f)@ t-N(o N(t) cf) t@N lr) N @(o (o(o N rO c\l rO rO o(f) oF$ oN rO @ f.-N sN N N t- l()N lolr)N @s cf) ()6N t-t- (f)(o @r.- @ro$ N s oooN ooN F.-ooN rOoo c{ F-ooN N o, o) f-ooN F,-ooN oooN ooN oooN rf)ooN ooN ooN N o, o) NooN f.- o, O) NooN f.-ooN F- O) O) NooN t- o, O) NooN f.- o) o) NooN F-ooN F.- o, O) NooN oooooolr)\N ooo (oo c!(o ooo (oo(.{ (o ooo F-(o(o rr) @ oooF(o(o q(o ooo @o <f) @\(o ooo(oo(o @\ @ ooo F-(o(o(o (f) d ooooo|r,Nq @ @ F* F*t-No$q t- ooo(o rr)o(f) r- ooooo l{)Nlr)(o ooo(o lf)lr) o, t- ooo(o oo (f) (o oooooolr)q rr) oooooo rOq rO ooos$ o, q|r) ooo$$ o, l()d ooot$ o) rr) rri ooo(o rr)o q rr) ooo(o r.r)o q rr) ooo F.- O)s rr)d ooot- O)$If) 'd ooo(o6os(, ,ri ooo(f) @oslr) ri ooo(f) @os|f)d ooo(o o(r) (Y)q rf) ooo(oo cf)(f)I r.c) ooo!ttt o) rO <"i oooN r.- o, O) rr) c.t I oooN F.- o) o)q(o oooooo rr)q (r) oooooolr)q (t) oooooo l.r)\(a oooooo ro\(A I ooo(oo(f)(o l.r) CO oooNNNNq(r) I o F.-F-|-No o)q (f) t ooo(o o@ q(.) I t-@(o(o @ $cl (r) I oooo r()NNq (f) I ooo(f) 1r)(o o,q (f) I oooooolO ro ri I oooo c)o 1oq (f) ooo O)@o@ ro c.j I ooo o,@@@ ro c.i ooo O)@@@q (f) I ooo(f, @ rO @ l.() c.j I ooo(a @ rr)(o r() c.i I ooo(f) @ ro(o to c., I ooo(f) @ ro (f, u? (f) I ooo@No@q(r) ooo@No@q(o I ooo@No@q (f) I oooooo rf)q (f) I Oooooo()q c.) {) .9o .o o Eo c) {)o E oo .o) o E oo {)o E oo {)o E oo {) o E oo {)o E oo {) o E oo {) o E oo {) o E oo {) o E o() {) o E oo {)o E o C) {)o E o C) .o o E oo {) o E o() {) o E oo {)o E oO .{) o E oO .o o E oo .o) o E oO .o o E oo {) E oJ {) E oJ {) E oJ {) o E o C) .o o E oo C ,6 o -o o CL CL Jp uJ o E oo c oo -o Lo o- o-)p = tuo =o(J c 6oo Loo CLfp = UI o =oo c '6 (U .cl Lo o- CLfp = ltJ o oo c th G' -o L o) o- o- p = ul o =oo c aD o -o o o- o- =p = UJ o =oo c '6 o -o ooof ! =tu o oo c '6 o -o ooof ! = tJJ o =oo c '6 o -o Lo o-q E = t.lJ o =oo c an G -o L ooq p = I,IJ o oo c o(E! L o) o- o-)p = ut o =oo c '6 o -o o) o- o.fp = uJ o =oo .Eoo -o Lo o- CLfp = tu o oo c '6 o -o L o CL o-5p = ul o oo tu o o() Lo =oJ lJJ o =o(.) o) =oJ uJ o =o(_) o) =oJ uJ o oo L o =oJ tu o =oo q) 3o -J I,U o oo L o) =oJ UJ o o C) o) =oJ uJ o =oo Lq) =oJ IJJo =oo Lo =oJ t.rJ o =oo o) =oJ ul o o C) Lo =o) uJo =oo L o) =oJ I.JJ o =oo Lo =oJ uJo =oo o =oJ E IJJ LL = tJ,lz o t(II f oz 6 tr d) otYz z E o x.Yz z I fz u U) U) fz LUaa l o\z tUJ(n Fz EHLU<o-, >t odt o d) tu 5lr l oz o :l oY ot !z o o f o )o 6Va= 'ra)-!r6ZY lr (J a oaa oJ o U)a oJ otvz o = z o = otrvz o =zo = o E.Yz o Bz o = otY :) oF :) oY o d.Yl oF :) o\. =otY :) oFf oY =otYf oFf oY oY tUz o oY ulz o oY I.IJz o oz z oz z (o(A o, ro o O)Nlr) @ o)$ f.-@\t t-@$ (o @(f) (Y) @(f) o6(f) o,N o)|.r) o) @Nlo s(f) O) ro @@ Nlr) o)N ro @@t @ @s N F-(o l() N F.-(o lr) N F-(o |.r) (o F-(o tr) (ot-(o ro $t-(o lr) sf.-(o r() tr) F.-(o|r) roN @ rO t- o) rO o,@s O)@$ o ci \o (D oooN NsN Nrt(o {) o E o O ooo(oo(f,oq @ oo oooo s z. c '6 o -o o o- o- p = tU o =o o o x o u 6 I m o m o F.- JAFl3/INF IDOC.2 Page 22 Table 3: Overview of CDTI in Cote d'lvoire Map 1. Prevalence of Mf in Cote d'lvoire. Pretreatment situation TAGAOI YAGA BOKOBA TIEKORON Year Eligible Villages Treated Villages Geographic coverage Population registered Population treated Therapeutic coverage 1997 156 50093 391 85 78.2 o/o 1 998 1 688 1552 91.9 o/o 699969 510912 73% 1 999 1685 1428 84.7 o/o 439425 31 5960 71.9 0/o 2000 1 685 234 13.9 0/o 123029 72710 59.1 o/o 2001 1 685 559 33.2 o/o 326979 182715 55.9 % 2002 1 350 839 62.1o/o 584300 375000 64.2 0/o 2003 No data 2004 200s 1 898 952 50.2 o/o 991 971 341677 34.4 o/o 2006 No data {i\I I JAF13/INF IDOC.2 Page 23 Map 2. Prevalence of mf in Cote d'lvoire E ical evaluations from 2000 to 2002 Map 3. Prevalence of Mf in Cote d'lvoire E ica! evaluations from June - J 2007 AWAHIKRO l BARNABE MONEKOI N IANDA zouzousso TOURESSO Carte 3. Pr6valences des Mf en C6te d'lvoire Evaluations 6pid6miologiques de juin - juillet 2007 BENIASSO FODIOLOKAHA PIEYE Limite de l'Aire lnitiale Limite des traitements larvicides '3":'::l ll or- slf.-.. ff'i :: f,oo l_ )) il \ l JAF 1 3/INF IDOC.2 Page 24 82,9 * Prevalence +Cmfl51,5 \-!.ttoffi Figufe l. Curves of trend in prevalence and CMFL at Vialadougou (upper basin of the Sassandra)l 977 - 2007. 1977 1979 t98t 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year o ,41 90 80 ,E 70(J 660 oHs0 oE40 9so o. 20 10 0 84,5 * Prevalence + Cmfl 57,A,98 8,93 FigUre 2. Curves of trends in prevalence and CMFL at Sorotana (middle Sassandra) 1 977 -2007 90 80 70 60 50 40 30 20 10 0 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year i= E o o oo g o E o- ,8 1977 1979 1981 JAF 1 3/INF IDOC.2 Page25 14,6(}. \- x l- Prevalence +Cmfl 1.5 oq 0 FigUre 3. Curves of trends in prevalence and Cmfl at Guesso-Bondosso (Upper Bandama) 1989-2007 16,0 14,0 12,0 10,0 8,0 6,0 4,0 2,0 0,0 EE o o oo o a6 E o- 0,00 2001 2003 2005 20071997 1999 Year 1989 1991 1993 1995 52,4 -# Prevalence +Cmfl 17,68 9,92 13,87 8,3 I Figufe 4. Curves of trends in prevalence and CMFL at Aouati (lower Bandama)1979 - 2007 . 70 60 50 40 30 20 10 0 1979 1981 1983 1985 1987 1989 1991 1993'1995 1997 1999 2001 2003 2005 2007 Year o o il) o o 6 o o- t 52,b \ \ L \ JAFI3/INF IDOC.2 Page 26 76,6 66,6 49,3 *Prcvalence + Gmfl 24,47 16,2 .1 010, FigUfe 5. Curves of trends in prevalence and CMFL at F6t6kro (upper-mid Nzi)1 977 - 2007. 90 80 70 60 50 40 30 20 10 0 1983 1985 1987 1989 1991 1993 1995 1997 1999 20ol 2003 2005 2007 Year G E c! o oo g C o E 1977 1979 1981 .J *Prevalence +Cmfl42,1 26,68 12,87 FigUfe 6. Curves of trends in prevalence and Cmfl at Laour6bo (lower Nzi) 1977-2007 80 70 60 50 40 30 20 10 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2oO3 2oO5 2007 Year ,2 Eo o o(, trg 6 EG 0 JAF 1 3/INF IDOC.2 Page27 40,2 *- Prevalence + Cmfl 34,0 1.5a2,4 1,8 Figufe 7. Curves of trends in prevalence and Cmfl at Ass6manou (Upper stretch of lower Como6 South 'Extension ) 1979-2007 70 60 50 40 30 20 10 0 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year E Eo o ooc o (E o o, 67,4 oz \oo * Prevalence +Cmfl \ TZJg u ,48 18, Figure 8. Curves of trends in prevalence and Cmfl at Blekoum (Mid stretch of lower Como6 , Soutti extension ) 1979-2007 80 70 60 50 40 30 20 10 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Year 52 E Eo o oo o .ll E o- JAF13/INF IDOC.2 Page 28 1 +Pteyalence +Cmf! 19,5 7,22 0,74 Figure 9. Curves of trends in prevalence and Cmfl at Awowonkro (Stretch of lower Comoe , (Out Extensioh zone ) 1997 - 2007 70 60 50 lo 30 20 10 0 1997 1 999 2001 2005 2007 E tr o o o() trg G oLo 2003 Year JAFl3/INF IDOC,2 Page29 u EPIDEMIOLOGICAL SITUATION OF ONCHOCERCIASIS IN GUINEA BISSAU Background information Guinea Bissau occupies 36 000 ltrr.2 at the western end of West Africa, between Senegal in the north, Guinea-Conakry in the east and south, and the Atlantic ocean in the west. The climate is the humid tropical type, with a low altitude and a less marked relief: some ten metres of altitude, except a few highs (100-200 m) south of Gabu in the extreme east of the country, near the border with Guinea-Conakry. The hydrographical network is made up of coastal rivers with large estuaries; the two major ones, rio Geba and rio Corubal, have a common mouth, and their upper basins are located in upper Casamance in Senegal (Kayanga for upper Geba) and in the western part of the Fouta Djallon in Guinea-Conakry (Tomine-Koliba or upper Corubal, and its tributaries, Kissen, Fefine-Senta). Population is about 1.5 miltion inhabitants. On several occasions, since independence, (1974) Guinea Bissau, a country among the less developed, according to the HDI, but which was acknowledged for the quality of its national health service, went through serious internal upheavals (civil war in 1993, 1998, 1999,2003,2004). Onchocerciasis in Guinea Bissau Onchocerciasis has since long been reported downstream of the Geba and especially the Corubal, where it constituted for the Portuguese colonial authorities air obstacle to agro- industrial development (SONACO). The integration of Guinea Bissau into the west extension area of OCP in 1988 triggered off a series of epidemiological and entomological surveys which made for the demarcation of the focus and to characterize the intensity of transmission and infection. Map No I illustrates the situation of the onchocercal disease at this period (1988-1990). The disease appears to be clearly restricted to two foci. The first focus, based on SONACO, less extensive and less affected, stretched over about forty km along rio Geba and downstream of its tributary, rio de Cuntimbo, at about sixty km as the crow flies upstream of the mouth of the river. The second focus, which is bigger extends from the entry of rio Corubal in Guinea- Conakry (Koliba in Guinea Conakry) upstream, up to about 100 km from the mouth of this river downstream (southern point of the Gabu region, on the level of Boe), on the Corubal itself and on the lower course of its main tributaries. Surveys undertaken from 1988 to 1990 (pre-treatment situation) in 20 villages of the rio Geba basin indicate the absence or "undetectable nature" of infection in 5 villages, prevalence (PVL) of 0.7 to 4.9%o in 3 villages, PVLs of 5.0 to l4.9Yo in 5 villages, from 15 to 30%o tn 7 villages: l2.l% (Canquenhe); 12.8% (Fulamory Djomel); 16.l% (Cahone); 20.4% (Meta JAF13/INF IDOC,2 Page 30 Seidi); 25.1% (Diabugo); 27 .7% (Sincha Side). All the villages of rio Geba were, thus, in the hypo-endemic area. Six villages showed zero CMFLs and 6 others CMFLs lower than 0.5 Mf/snip; in the other eight villages CMFLs ranged between 0.83 and 6.51. (cf. tables 2 anll 3). Again from 1988 to 1990, surveys conducted in 71 villages of the basin of rio Corubal, showed 5 villages without detectable infection, 6 with PVLs of 0.0 to 4.9%io, 10 with PVLs of between 5.0 and 14.9o/o,22 wtth PVLs between 15.0 and 24.9yo,4 with PVLs of 25.0 - 29.9o4, 17 with PVLs of 30.0 to 44.9o/o, 5 with PVLs of 45 to 59.9% and 2 with PVLs above 60% (63.5 at Cabuncara,72.7o/o at Bantaquilin). 47 villages (213 were thus hypo-endemic, 22 (30%) in a meso-endemic area (thus 4 between 50 and 60% of PVL, close to the hyper- endemic threshold) and only two in the hyper-endemic area, considering only PVL values. These figures are characteristic of a meso-endemic focus, reaching just the hyper-endemicity at the highest points of transmission per inhabitant. Microfilarial loads showed zero CMFLs, 17 villages showed CMFLs lower than 0.5 mf/snip, 23 villages had CMFLs between 0.5 and 5 mf,22 villages CMFLs between 5 and 30 mf and 3 villages had CMFLs ranging between 30 and 60 mf/snip. (cf. table 2 and 3). The population at risk was estimated at about 190 000, among whom 30 000 were said to be infected, and 1400 blind. Blindness rates could go up to 5Yo in the most infected villages of rio Corubal. Onchocerciasis control Though incorporated into OCP in 1998, Guinea Bissau never benefited from vector control. Thus, considering the epidemiological survey results on the one hand, and taking into account the advent of ivermectin on the other, a decision was made to control onchocerciasis in Guinea Bissau through chemotherapy only, i.e. per ivermectin, as in other hypo and meso- endemic regions of the western extension (eastern Senegal, Senegal River basin in Mali, Fouta Djallon in Guinea). Since the results of epidemiological evaluation in the early part of the 2000s (see further) were deemed satisfactory, no area of specific interest entailing assisted reinforcement of CDTI was put in place in Guinea Bissau upon closure of the OCP at the end of 2002. No information on past or current overall and detailed results of the implementation of CDTI, was available, and it is presumed to have been introduced in 1997 (some sources indicate that it was introduced in2004) in the whole of Guinea Bissau, as in the other OCP countries. From 1990 to 1993 (four years), ivermectin was distributed every three months (quarterly). Distribution was disrupted in 1993 and intemrpted from 1998 to 2000 by civil war. There is no indication to suggest that it was resumed on an annual, half-yearly or quarterly basis. The leadership of the NOCP, which manages CDTI, was deprived of its leader in 2005 due to the death of its coordinator, Dr A. Tamba Nhaque, who led it from its inception with devotion and exemplary efficiency. It is only this year that a new coordinator was nominated. JAF I3IINF IDOC,z Page 3 1 Results of epidemiological evaluation Evaluation network The epidemiological evaluation network of Guinea Bissau is made up of 94 villages, of which 29 were visited more than twice. It is a dense network, given the relatively limited extent and the endemicity in the dual foci. Standardized surveys took place in 1988-89-90 (pre-treatment data collection,97 villages), in 1995 (5 villages), in 1997 (25 villages), in 2001 (evaluation prior to the closure of OCP, 37 villages), in 2004 (19 villages), and in 2007 (33 villages). Due to circumstances, this is a convenient follow-up. out of 33 villages visited in2007,7 were visited in2004,16 in 2001, 13 in 1997,5 in 1995, l4 in 1990, l1 in 1989 and2 in 1988. Ten of them were never visited (they generally replace reference villages, which might have been abandoned for various reasons); only 5 villages were evaluated in 2007,2004,2001 and 1997. (cf. table 4). Results of 2007 They are in table 1 and illustrated by map No5 On rio Geba, the situation is clear, since in 9 villages visited PVLs and CMFLs are all nil On rio Corubal (table 1), 18 villages out of the 24 visited show that PVL and CMFL are nil. In 5 others, PVLs and CMFLs are below the acceptable thresholds of 5Yo and 0.5 mf/snip respectively: Madina-Djargandogo (PVL l.l}yo, CMFL 0.07); Rauna (PVL 2.30yo, CMFL 0.10); Sutuco (PVL 2.40yo, CMFL 0.14); Tabadara (PVL 2.70yo, CMFL 0.13); Cabuca @VL 4.50.o , CMFL 0.21).'In only one village, PVL and CIMFL are'above thejse thresholds: Cuatche (PVL 9:70Yo, CMFL 0.52). The 6 positive villages are all on the border or close to the border with Guinea-Conakry on the reach of 70 km between the entry of the river in Guinea Bissau and its confluent with rio Fefine, or on some tributaries: rivers Caium, Seli, and Campont. Prior to treatment, all these villages were themselves hyper-endemic, within the most infested concentrated communities of the focus. Prevalence and CMFL trends (cf. tables 2 and 3) ln1997 (cf. map No 2), after 9 years of treatment: . out of 10 villages visited on rio Geba, only 3 remained mildly positive: Fulamory (PVL 0.6yo, CMFL 0.00), Tabassaye (PVL 0.5o , CMFL 0.00), Meta Seidi (PVL Ll%, CMFL 0.01). Everywhere else, PVLs and CMFL were nil. o out of 15 villages visited on rio Corubal, 8 remained positive, 6 with PVLs <5o/o andZ with PVLs of 12.2%o (Tabadara) and 10.8% (Coboncara), all showing CMFLs lower than 0.5 mf/snip: 7 with CMFLs that are nil, (6 with CMFLs lower than 0.1 and two with CMFLs of 0.21 and 0.2). No village was already in a meso-endemic situation. In 2001 (cf. map No3), after 13 years of treatment JAF13/INF IDOC.2 Page 32 . on rio Geba, prevalence rates and CMFLs were already all nit in the l2 villages visited. o On rio Corubal, out of the 25 villages visited, no infection was detected in 16 villages, and PVLs were below the threshold of 5% in 6 others (PVLs of 0.6, 0.7, 0.8, 1.0, 1.5, 4.3oA), below 30Yo in 2 others (11.8% at Quewe on rio Fiefine and23.6% at Cuatch6 on the border between the two Guineas) and above 30o/o in only one village: Coboncara also on the border: PyL 35.6%). For the same villages, CMFLs were 0.03, 0.01, 0.08, 0.02, 0.05, 0.18, 0.41, 0.71, and 0.77 respectively, i.e. above the tolerable threshold in 6 cases, close to this threshold in one case and above the threshold in two cases. In 2004 (cf. carte No4), out of 19 villages visited, 17 showed PVLs and CMFLs that are nil; prevalence rates and CMFLs of two othervillages were 6.6% and 0.18 mf (Cabuca) and2.6Yo and 0.09 mf (Cuatche) (map No 4). Prevalence rates and CMFLs show a general drop beginning 1997, since all the villages examined became hypo-endemic (as against only 57 out of 91 prior to the beginning of treatment) and that only two villages out of 15 visited showed PVLs above the tolerable threshold (as against 72 out of 91 before treatment started), with CMFLs being everywhere lower than the threshold of 0.5 and often very low or nil. (cf. tables 2 and 3 and trend curves of PVLs and CMFLs). While values of the two parameters remained low, or even nil for about ten years, it must however, be noted that marked increases were recorded in 2001 in several villages of the basin of rio Corubal (ex: Cuatche, Cobuncara and Quewe). One could correlate this recrudescence in the villages, among the most infected initially, with the intemrption of CDTI between 1998 and 2000. PVLs then significantly dropped, though they shot up again in 2007 at Cuatche above the acceptable thresholds; at Camedina PVLs have been close to this threshold since 2001, and villages with recrudescence in 2001 have not been visited since this date (ex Cobundara, Quewe). (cf. fig. I to 5). Comments and recommendations It would be interesting to ascertain if the initial spectacular impact of CDTI on infection indicators has a link with the relatively low level of endemicity in the foci in the 1980s, or if the application of a quarterly distribution of ivermectin could have had an impact on the rapidity and extent of regression of PVL rates and CMFLs. It is also necessary to compare the trends observed in the last years (since 2001) with the continuity of regional coverage and CDTI quality. Transmission appears to be intemrpted on rio Geba, and in future, the continuation or cessation of control, as well as the surveillance plan on this basin should be based on information from the programme, led by TDR, APOC, and MDSC, on the basins of the Faleme, Bafing and the Bakoye. Positive villages of rio Corubal in 2001 should be visited in 2008 (except those which were visited in 2007) so as to specifically demarcate areas of residual transmission. Villages that were positive in2007 should undergo socio-demographic surveys and CDTI surveys. Their status as border villages is such that one cannot exclude the possibility of contamination from adjacent foci of Guinea-Conakry, which might miss CDTI, either in the upper basin of Rio Corubal and its tributaries or in the neighbouring basins (example JAF13/INF IDOC.2 Page 33 of the Kogon, though surveys following previous wamings did not detect residual transmission). Cross-border population movements also disrupt CDTI coverage, even if it is well implemented on both sides of the border. A border epidemiological survey by teams of Guinea-Conakry should thus help to enhance CDTI in Guinea Bissau, and as a matter of priority, on Rio Corubal, as well as epidemiological surveys in Guinea Bissau villages that show residual infection. One or two entomological surveillance points should be followed up per pool-screening. Annexes Map Nol: Prevalence of Mf in Guinea Bissau. Status of pre-treatment Map N'2 : epidemiological survey of 1997 Map No3 : epidemiological survey of 2001 Map N'4 : epidemiological survey of 2004 Map No 5 : epidemiological survey of 2007 Table 1 Table 2 Table 3 Table 4 : Results of epidemiological evaluations in Guinea Bissau, 2007 : Trend in PVLs in Guinea Bissau from 1988-1990 to2007 : Trend in CMFLs in Guinea Bissau from 1988-1990 to 2007 : Trend in PVLs and CMFLs in 5 villages from 1997 to2007 : Curve of PVL and CMFL trends at Meta Seidi (rio Geba) : Curve of PVL and CMFL trends at Cabuca (rio Corubal) : Curve of PVL and CMFL trends at Cuatche (rio Corubal) : Curve of PVL and CMFL trends at Cobuncara (rio Corubal) : Curve of PVL and CMFL trends at Quewe (rio Corubal). Fig. Fig. Fig. Fig. Fig. 1 2 aJ 4 5 JAF I 3/INF IDOC.2 Page 34 Map 1: Prevalence of Mf in Guinea-Bissau. Pre-treatment situation (1988-1990 Carte 1 : Pr6valences des Mf en Guin6e-Bissau. Situation de pr6-traitement (1988-1990) SARE.' IUAOINA SARE NAI DEMBA SINTCHA.SIDE CHAIIRA o (>o PREVALENCE (%) at Oo s(l sr-rs [::;::: H JAF13/INF IDOC.2 Page 35 Map 2: Prevalence of mf of villages evaluated in 1997 in Guinea Bissau Carte 2 : Pr6valences des mf des villages 6valu6s en 1997 en Guin6e Bissau FULAMORY DJOMEL COLONDINTO o TCHE ,TABADARA PREVALENCE (%) / # Map 3: Prevalence of mf of villages evaluated in 2001 in Guinea Bissau Carte 3 : Pr6valences des mf des villages 6valu6s en 2001 en Guin6e Bissau at Oo s Orsr-so 3:":3 oANGUTRo-O FULAMORY CANSANUMA DANSSY OADY c CHAMM PREVALENCE (O/O)# x:,.: ili,;; ;; 3:" :: at L>o o o JAFl3/INF IDOC.2 Page 36 Map 4: Prevalence of mf of villages evaluated in 2004 in Guinea Bissau Carte 4 : Pr6valences des mf des villages 6valu6s en 2004 en Guin6e Bissau Map 5: Prevalence of mf of villages evaluated in 2007 in Guinea Bissau Carte 5 : Pr6valences des mf des villages 6valu6s en 2007 en Guin6e Bissau Cahone Rauna 4 Guiledje Cobolo Orc-Tchon Camedine Pr6valen@ % 00 , fu,'J O 0,.6 t,, tiii at 1530 60 SARE OJIOE CUPUDA MANSACUNDA MAUNOA c o >o # ! aI PREVALENCE (%) Oo -sG s.r -rs $::r.:: Seido t>l? o o FACl3/INFIDOC.2 Page37 Go f-ooN f-ooN NooN r\ooN t\ooN t\ooN r-oo e! t-ooN o @ o) sooN o) @ o) ooN o o) o) sooN sooN o)o o) r sooN sooN ooN t\ o) O) ooN sooN ooN sooN F-ooN io Gto o- oo o oo o oo o oo C; oo C; oo C; oo ci oq o oo c; oq(o o@d oq r o a F-(f) oo o oo C; oq N(r) oo C; oq o oo c; oo c; oo o oq o oo c; oq N oo C; l! =o o o o o o o o o o q o o o o o oo o oo o $ o oo C; oo C; oo C; t-q o (f) r C; oq o oo o N!o o o Bei(/, oo C; oo o oo C; oo C; oo o oo C; oo o oq o oo ci o rot oo C; oo C; o c) Cri oo ci oo o o a(\ oo ci oo o oo C; o o\N oo o oo C; o\ o) oo o o .z .= o o o. o o o o o o o o o ct) o o 6t o o c':, o o o o o (0 o !, tr Gx UJ ro$ o(o t-t- NcoN @N os (f)o, rO oI\ ooN s o) N@r (o o) st- so ro r O)Nr I\t\ sro slo os o)@ NrN N(o N@ o oo -ct @lo t\@ (f,oN oo s N(r) @(o o)N T\rO o)oN s@ (f)ro o(f) s|r) N(f) @(f) (o@ sr [o(o (oo r o(o N $s f-ro (f)s oo o o- ro r o) r (f)t\ (f) lo(o (f) ro(o ro(o o)roN o co r r N o, (f) os r (oo (f) o) o) o) (oN t*s r rO o)N rI\r o)(o rO (o(f) o$(f) (f) roN @ r E' .9 E, ot (Y)o r t*N r oo (f) N@ (f) o)(o Nt\ r(oN o@ t-N r o)o$ @lo r r.o(f) (f) (o N r @N r (o cf)r (olo r lf) (r) r O) Nt\ o) (os t-rr)(f) (oloN o, rON c o = t\ t\ r\ t- t- t\ t- @ @ t- l- r- t\ t\ t\ N r\ t- T\ t\ f- @ l- t- @ G o NooN f-ooN f-ooN f-ooN t-ooN F-ooN F-ooN 1.-ooN r-ooN f-ooN t-ooN t\ooN t-ooN t\ooN t-ooN t-ooN t-ooN r\ooN t\ooN F-ooN r-ooN FooN 1.-ooN t-ooN r-ooN o o(E o E _of,LoO EofLoo 6 -of oo 6of,L oo 6 -of oo E -of oo 6 -of oo E -o =oo 6 -of oO E -of oo 6 -of oo E -o =Loo 6 -ofL oo E -ofLoo E -of oo E -ofL oo E -ofL oo E -ofL oo E -ofg oo E -ofL oo E -ofL oo ([ -of oo E -ofL oo E -ofLoo (U -oo o oo EDg ooc o iE o o _o oo cfEc(! o (E oq fo(5 -o o) i5 o E-g f, o Co .CoF IoL o (! c([ E([ a o c (tr a c(56 (5 c(5 aa (5 of -o(E o op o _o E(s o .g o(,J([ a oCl(Et .c =oE(U C(5 o E o)L(5 i5 o(J J fa o .=o c) E(tr o oC(5(, Io -o E(5 a o(E o I(5s() L a o o)c oE Po .=h HE' > ir- ([ L(U o(5 -ooF .oE(5 I(E -co .sa o =Ec o oo oEo (E fo o .Cc of -g(5 U) oE' oo lo O) (f)s (o O)(f)s t- O)(f,s @ O)(f)s O) o)(a!t oos$ o\t$ (f)os$ (oolos (f, rlo$ s ro$ o) r rOs oN rOs (f)N!os ro(Y) rOs @(o TO$ o)(f) tos (os rOs rolr) ro$ o) ro ros ot\ ros r co rOs f* co ros r o, rr)s No$s z o D uJ dEOo6Iqi =aYO =mlUT dglu= 6oOZ 'r A = lJJ6o J olt =oEo IJJF g tt(g F uooN ooN ooN ooN ooN ooN ooN oo C; oq o oq o oo o oo c; oo c; oo c; o oo CJ oo CJ oo C; oq o oo C; oo c; oo C; oo CJ oo CJ oo C; oo c; oo C; oo o o o o o o o o (o T\ o)LOr (f)s r t-N lf)s lr)!t (f) O) ooN sN ro N r*o r s(f) (f)oN lo(f) N (oo(f, (o (f) (f) @N(f) o)to roo) O)(f)(f) (o (f) N t-N(f) @@(f) o(o (f) @o or N@(f) @ @ @ o @ t- @ t-ooN T\ooN r-ooN t-ooN l-ooN F*ooN f*ooN (u -o o)(, (5 -ooo (5 -o o) o (5 -o0) o (5 -oo o (tr !o o (5 -o o) o (E -oo C(U L([ o oL o E(5)II (! Eac(E ac(5 o o)c o -c(5 o op o)a o 0) = o o)) -o(5 i5 oL(s E(5 o r ro$ @Nlos o)N rf)s os ltr)s ss ros roolo$ o @lr)s FACI3/INF/DOC.z Page 38 NooN oo C; o oo C; o N(o r NN s@ s@ @ t-ooN (5 _o G) o o C,(u Eaool soss I(5 -co .E U) FACI3/INFIDOC.2 Page 39 oo(\t E .e€tro o \tN @ ro o) (f)N o o oE izE o) O) o) o) o o tooN E o€trb o (a N (f) o o oE iEE @ (o (o (o o o ooN Gll oo .9t tr)N (o (o r NN $N o oEitE N N N (\ o o CD o) E o€trb o lo t- (o N (f) rO o o oEizE or t- (f) o o o o lO o) o) E .e€trb o o o o oEiiE !t (f) \t s o o Oo)8eE(E oStoE PE o E .e€trb o r- rO (o o NN s t- lO N N$ NN N oEitE oN lO (r) rO rO (\ t- (r) o o o '6 (E o !o (E fbE ci o) -aht o,s sq o J 0- .C ,= s lf) J o- = = J O- -oVo\ -oQo-$q)r ! = = s o? sN()V OJai s Lo r sq o,N()VOr &a s ro N sq$!t()VOJia so(f) s o? 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E o€trb o ro N (o r lr) N N (o N oE iEE N N N o) o) E o€trb o ro t- (o N lO oE iuE o o) o to o) o) ii o€trb o oEizE s (f) s cro8sqiE oE,oE30 o- E o€trb o t\ (o N lo (f)N @ (f) (f) (f) N (E ! oo o E oN tr) lr) t- N o 'd (E o oo ED E'(E6) =(E>= bE doz =L J tL o o J tL o u? o -JLL o C; rr) J LL o q o o -JLL () lf) oN J tL C) o o(9 JII o oN o(o J tL o o (f) EE ah o e to 61VI E -JOlrh z.o Noo ot o o o)I @ € CD !F E oL (E lt L oo o E E'c(E (Elt o o o E o oJlr =o .s !,tr oLF o.i o Il GF Go oo ot lr =o oo o c! o oo o Nq o oq o (L q o u? s co t- o q o $oo$t lJ. =o oq co o oq o O)q o oq o o- q o q(o qo q?N qo ooN lr =o Nq o @co (f)q o \o -co q o? s q o q (f) \o (n CD lt =o N o l.()q o (oq o ro c! o roq o L o) o aN 6 r q N oq cooo)Eor.LEiEOE'a)E PO o. lJ. =o lr)\ NN o (f) 'ri t- c? o c!(f) t-q(\l IL \ Nt- ro CJ$ q $(Y) q (9 q ss U) lU(, z J 5 o Fz m of,o o z o UJ =o IU I o f o z o o E U) clH YorL/ ho <o.f&z c.t (J f& tr '6 (E lt (E -o o o .9t o +. o o o C" s ro .= oJ tI. E o ttc(U oJ o. .= Itcg F + -g .ct oF FACI3iINFIDOC,2 Page 42 t * Prev. Pop. +Cmfl 24.4 \ -^o''' o,o, 00\ Figure 1. Curves of prevalence trends & Cmfl at Meta Seidi (Rio Geba) 1 990-2001 E E o o ooc o) G E(L 2001 2003 2005 20071989 1991 1993 1995 1997 1999 Year *Prev. Pop. +Cmfl 48,5 18 4,32,45,22 Figure 2. Curves of prevalence trends & Cmfl at Cabuca (Rio Corubal) 1 989-2004 70 60 50 40 30 20 10 0 G E o r1)() oco 6 E(L 2001 2003 2005 20071991 I 993 1995 'l 9971 989 1 999 Year 70 60 50 40 30 20 10 o ,{s.36 \ FACl3/INF/DOC.2 Page 43 a a Prev. Pop. Cmfl Figure 3. Curves of prevalence trends & Cmfl at Cuatche (Rio Corubal) 1 989-2007 70 60 50 40 30 20 10 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year 4 31.5 v, /a\23'6 -/\ 9,72,60,71 c) 0)oc ot>EEEL() +Prev. Pop. +Cmfl Figure 4. Curves of prevalence trends & Cmfl at Cobuncara (Rio Corubal) 1 989-2001 70 60 50 40 30 20 10 0 tux. 29,21 -yrrv," \ 7 10,8 1989 1990 1991 1992 1993 1994 '1995 1996 1997 1998 1999 2000 2001 2002 Year Eo o) ooc o) (U p TL FACI3/INFIDOC.z Page 44 +Prev. Pop. +Cmfl Figure 5. Curves of prevalence trends & Cmfl at Quewe (Rio Corubal) 1 990-2001 70 60 50 40 30 20 10 0 59,9 ',N \ \ \ 11,8 --a 1,7 0,41 - 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year Eo o o() o o I o- I